nutrition care process and change management: making it happen in dietetics!

© 2006 American Dietetic Association ADA)

Nutrition Care Nutrition Care Process and Change Process and Change

Management: Management: Making it Happen Making it Happen

in Dietetics!in Dietetics!Nutrition Care Process/Standardized Language Nutrition Care Process/Standardized Language CommitteeCommittee

September 2008September 2008


This presentation is This presentation is for you if…..for you if…..

1)1) You are a nutrition You are a nutrition manager getting ready manager getting ready to implement NCP at to implement NCP at your facilityyour facility

2)2) You are a member of an You are a member of an NCP implementation NCP implementation teamteam


Change is a challenge but Change is a challenge but the rewards are great!the rewards are great!

Effective application of Kotter’s 8 Effective application of Kotter’s 8 step change management process step change management process can enable your team to can enable your team to successfully implement the Nutrition successfully implement the Nutrition Care Process Model and Care Process Model and Standardized Language while Standardized Language while minimizing the barriers usually minimizing the barriers usually associated with change.associated with change.


8 Stage Process of Major 8 Stage Process of Major ChangeChange

1.1. Create sense of urgencyCreate sense of urgency

2.2. Develop leadership teamDevelop leadership team

3.3. Create shared vision and strategyCreate shared vision and strategy

4.4. Communicate vision and strategyCommunicate vision and strategy

5.5. Empower broad action and align Empower broad action and align organizationorganization

6.6. Celebrate short term gainsCelebrate short term gains

7.7. Consolidate short term gains and create Consolidate short term gains and create opportunityopportunity

8.8. Institutionalize changeInstitutionalize change‘

(Listed in Chronological Order)

Leading Change' by John P. Kotter, Harvard Leading Change' by John P. Kotter, Harvard School Press 1996School Press 1996


Your Role as Change Your Role as Change AgentAgent1.1. Establishing a sense of urgency Establishing a sense of urgency 2.2. Creating the leadership group Creating the leadership group 3.3. Developing a vision and strategy Developing a vision and strategy 4.4. Communicating the change visionCommunicating the change vision5.5. Empowering broad-based action or aligning the Empowering broad-based action or aligning the

organizationorganization6.6. Generating short-term winsGenerating short-term wins7.7. Consolidating gains and producing more change Consolidating gains and producing more change 8.8. Institutionalizing new approaches in the cultureInstitutionalizing new approaches in the culture

Leading Change' by John P. Kotter, Harvard School Press 1996Leading Change' by John P. Kotter, Harvard School Press 1996 Handout with Steps to help you assess your progressHandout with Steps to help you assess your progress


Stage 1:Stage 1: Creating Sense of Creating Sense of UrgencyUrgency

What is relevant to your institution?What is relevant to your institution? Do Students/interns know more than their Do Students/interns know more than their

preceptors about NCP?preceptors about NCP? Regulatory agencies are beginning to ask how Regulatory agencies are beginning to ask how

NCP is integrated into patient careNCP is integrated into patient care Evidenced based care-requirement for clinical Evidenced based care-requirement for clinical

practicepractice Lead the charge verses lagging behindLead the charge verses lagging behind Recruitment edge for new RDs- how you differ Recruitment edge for new RDs- how you differ

from your competitorsfrom your competitors Need to justify staffing- NCP provides a Need to justify staffing- NCP provides a

systematic way to collect outcome data on systematic way to collect outcome data on impact on nutrition care.impact on nutrition care.


Stage 2:Stage 2: Creating Creating Leadership TeamLeadership Team

What has ADA Done?What has ADA Done? BOD, HOD and CommitteesBOD, HOD and Committees

Your Team (at each institutional this will vary)Your Team (at each institutional this will vary) Formal leaders (Dept head, CNO, CNM, IT, Medical Formal leaders (Dept head, CNO, CNM, IT, Medical

records)records) Informal leadersInformal leaders Individuals who are willing to go first and pilot the Individuals who are willing to go first and pilot the

process (evaluate individual staff members present process (evaluate individual staff members present learning level and acceptance level in regard to learning level and acceptance level in regard to NCP)NCP)

Consider variety of practice experience (veteran + Consider variety of practice experience (veteran + new)new)

Individuals who are great at reward and recognitionIndividuals who are great at reward and recognition Process peopleProcess people Everyone needs a role! Everyone needs a role!


Stages 3 & 4:Stages 3 & 4: Creating & Creating & Communicating a Shared Communicating a Shared

Vision and StrategyVision and StrategyADA’s Actions:ADA’s Actions: Implementation Strategy: provide Implementation Strategy: provide

resources to key target audiences resources to key target audiences first: Educators, CNMs, practitionersfirst: Educators, CNMs, practitioners

Specific ActionsSpecific Actions President’s presentations include NCPPresident’s presentations include NCP ADA Board of Directors updatesADA Board of Directors updates DEP & CNM presentations show applicationDEP & CNM presentations show application FNCE sessions highlight implementationFNCE sessions highlight implementation Creation of Peer Network of early adaptorsCreation of Peer Network of early adaptors

What actions will you take at your What actions will you take at your facility?facility?


Stages 3 & 4:Stages 3 & 4: Creating & Creating & Communicating a Shared Communicating a Shared

Vision and StrategyVision and StrategyYour Actions:Your Actions: Create your own personal vision to help direct Create your own personal vision to help direct

the change effortthe change effort Develop strategies for achieving that visionDevelop strategies for achieving that vision Be able to articulate the benefits of NCPBe able to articulate the benefits of NCP

Consistency of documentationConsistency of documentation Communication with other disciplines etc.Communication with other disciplines etc. Outcomes reporting with potential reimbursement Outcomes reporting with potential reimbursement

possibilitiespossibilities Provide key resources at www.eatright.org: Provide key resources at www.eatright.org:

NCP presentations, FAQs, Lacey and Pritchett NCP presentations, FAQs, Lacey and Pritchett article , NCP IDNT reference manual and article , NCP IDNT reference manual and pocket guide pocket guide


Stage 5:Stage 5: Strategy 1: Determining Plan Strategy 1: Determining Plan

of Implementationof Implementation Establishing a timeline: ADAEstablishing a timeline: ADA

10 years for full 10 years for full implementation in professionimplementation in professionIn Year 4 nowIn Year 4 now

Education must come firstEducation must come firstSupport from Department and Support from Department and

Clinical ManagersClinical Managers


Strategy 1: Determining Plan Strategy 1: Determining Plan of Implementation continuedof Implementation continued

Establishing your own personal timelineEstablishing your own personal timeline Varies by institution: ( 2-6 months)Varies by institution: ( 2-6 months) Assess present learning level and readiness Assess present learning level and readiness

level of your staff: Education must come level of your staff: Education must come first. Teaching resources available at first. Teaching resources available at www.eatright.orgwww.eatright.org

Make it realisticMake it realistic Build in enough time for practiceBuild in enough time for practice Identifying things that can hold up the Identifying things that can hold up the

process: Lead time necessary for changes in process: Lead time necessary for changes in EMR or paper documentation, significant EMR or paper documentation, significant staffing changesstaffing changes

Many sample timelines available. Many sample timelines available.


Implementation Plan Implementation Plan continuedcontinued

Assessing impact and barriersAssessing impact and barriers Determining documentation system (paper vs Determining documentation system (paper vs

EHR)EHR) SOAP, Narrative, ADI or ADIME, or otherSOAP, Narrative, ADI or ADIME, or other

Assessing education needs and developing Assessing education needs and developing programsprograms

Frustration, RD’s need to be perfect, it takes Frustration, RD’s need to be perfect, it takes longer at first.longer at first.

Prepare and anticipate the hard questionsPrepare and anticipate the hard questions If your institution uses a method to calculate If your institution uses a method to calculate

RD productivity- what will be the impact and RD productivity- what will be the impact and who needs to be aware? who needs to be aware?


Stage 5:Stage 5: Strategy 2-Identifying Strategy 2-Identifying Performance Improvement Performance Improvement

plan/measuresplan/measures What Has ADA Done?What Has ADA Done?

Charney’s Research (Entry level vs other Charney’s Research (Entry level vs other experience/expertise levels)experience/expertise levels)

CARLE Research Project – Nutrition Diagnosis CARLE Research Project – Nutrition Diagnosis in Ambulatory Medicare populationin Ambulatory Medicare population

Pilot Projects – Virginia and VA in San DiegoPilot Projects – Virginia and VA in San Diego DPBRN Standardized Language – Four settings DPBRN Standardized Language – Four settings

(Ambulatory, Long-Term Care, Outpatient, (Ambulatory, Long-Term Care, Outpatient, Renal)Renal)

Standardized Language SurveyStandardized Language Survey NC BCBS- Nutrition Dx and Intervention – NC BCBS- Nutrition Dx and Intervention –

Ambulatory overweight populationAmbulatory overweight population ADA Dietetics MeasureADA Dietetics Measure


Identifying Performance Identifying Performance Improvement Improvement

plan/measures plan/measures cont…cont… What Can You Do?What Can You Do?

Staff competency validationStaff competency validationProductivity measuresProductivity measuresStaff Satisfaction MeasuresStaff Satisfaction MeasuresOutcome studies: resolution Outcome studies: resolution of specific nutrition of specific nutrition diagnosisdiagnosis


Sample Staff Satisfaction Sample Staff Satisfaction ResultsResults

(one month post implementation)(one month post implementation)

QuestionQuestion Avg. Avg. ScoreScore

Feel comfortable & confident in writing PES Feel comfortable & confident in writing PES statementsstatements

3.73.7

PES case study assignment & review was helpfulPES case study assignment & review was helpful 4.14.1

Writing PES statements has decreased my Writing PES statements has decreased my productivityproductivity

2.42.4

Find reassessing PES in follow-ups to be Find reassessing PES in follow-ups to be problematicproblematic

3.23.2

Resources & guidelines provided are helpful in Resources & guidelines provided are helpful in writing PES statementswriting PES statements

4.64.6

Scale: 1=strongly disagree 2 =disagree 3 =somewhat agree 4 =agree 5 =strongly agree (n = 31 dietitians)

Resource: 2006 UPMC Presbyterian Shadyside, S. Jones, MS, RD, LDN


Stages 6 & 7:Stages 6 & 7: Measuring and Measuring and Celebrating GainsCelebrating Gains

Identifying short term gainsIdentifying short term gains First RD to implement (reward and recognize First RD to implement (reward and recognize

staff all throughout- remember, recognition staff all throughout- remember, recognition doesn’t have to cost money, certificates, doesn’t have to cost money, certificates, balloons, buttons, silly prizes etc.)balloons, buttons, silly prizes etc.)

First floor or unit to implementFirst floor or unit to implement First training completedFirst training completed Support by institution (Department Head, Support by institution (Department Head,

Medical Staff, Information Systems, Medical Medical Staff, Information Systems, Medical Records)Records)

Consolidating gains and creating better Consolidating gains and creating better opportunities for future changeopportunities for future change Use Performance Improvement principlesUse Performance Improvement principles Revise guidelines/materials as neededRevise guidelines/materials as needed


Stage 8:Stage 8: Institutionalizing Institutionalizing ChangeChange

Change policies and procedures, standards Change policies and procedures, standards of care, and chart audit forms to reflect of care, and chart audit forms to reflect new processnew process

Destroy old forms to avoid relapseDestroy old forms to avoid relapse Revise orientation program and Revise orientation program and

competency check off for new employees competency check off for new employees to include NCPto include NCP

Revise student/intern curriculum if clinical Revise student/intern curriculum if clinical sitesite

Ensure ongoing monitoring measures Ensure ongoing monitoring measures continued progresscontinued progress


Real-Life Pilot Test Real-Life Pilot Test ResultsResults

Initiating Nutrition Diagnosis: Initiating Nutrition Diagnosis: Hospital PilotHospital Pilot

NOTE: This pilot project started as a NOTE: This pilot project started as a dietetic intern project – provide an in-dietetic intern project – provide an in-service to RD staff on the Nutrition Care service to RD staff on the Nutrition Care ProcessProcess

Adapted from Mandy Foust’s work at Adapted from Mandy Foust’s work at Virginia Hospital, Arlington VA (2005)Virginia Hospital, Arlington VA (2005)


Pilot Project DescriptionPilot Project Description

To improve consistency and quality of To improve consistency and quality of carecare Implementing Nutrition Care ProcessImplementing Nutrition Care Process Implementing new documentation format that Implementing new documentation format that

reflects the Nutrition Care Processreflects the Nutrition Care Process Consistent communication with other healthcare Consistent communication with other healthcare

providersproviders

Use of quality improvement principlesUse of quality improvement principles PDSA approach (Plan, Do, Study, Act)PDSA approach (Plan, Do, Study, Act) Organizational change, provider education, Organizational change, provider education,

audit and feedbackaudit and feedback


Charting Charting Format: Format:

From ADIME to From ADIME to ADIADIInitial Charting Initial Charting

FormatFormat AssessmentAssessment Diagnosis, Diagnosis,

NutritionNutrition InterventionInterventionSubsequent ChartingSubsequent Charting MonitoringMonitoring EvaluatingEvaluating

Modified after use toModified after use to Assessment or Re-Assessment or Re-

AssessmentAssessment Diagnosis, Diagnosis,

NutritionNutrition InterventionIntervention

Include specific Include specific plan for follow-up plan for follow-up monitoring and monitoring and evaluatingevaluating


Initiating the ProcessInitiating the Process Meet with clinical RD team – agree to Meet with clinical RD team – agree to

initiate pilotinitiate pilot Introduce through email and meetings to:Introduce through email and meetings to:

VP over Nutrition ServicesVP over Nutrition Services Chief Nursing Officer or Director of Chief Nursing Officer or Director of

NursingNursing VP of NursingVP of Nursing President of Medical StaffPresident of Medical Staff Nutrition Committee DirectorNutrition Committee Director Director of Education and ResearchDirector of Education and Research


Training Process – Changing Training Process – Changing our way of thinkingour way of thinking

Training sessions with individual staff Training sessions with individual staff dietitiansdietitians

Weakest area – PES/diagnostic statementWeakest area – PES/diagnostic statement Practice makes perfectPractice makes perfect Weekly meetings with dietitiansWeekly meetings with dietitians

As one RD gears up to pilot, the others As one RD gears up to pilot, the others bring practice notes for review to my officebring practice notes for review to my office Focus - Nutrition Diagnostic Statement Focus - Nutrition Diagnostic Statement

and consistency from Assessment and consistency from Assessment through Interventionthrough Intervention


Adapting Evaluation Tool for the Adapting Evaluation Tool for the Chart NoteChart Note

1. Was a nutrition problem/diagnosis identified? Yes1. Was a nutrition problem/diagnosis identified? YesNoNo

If yes: Evidence for Assessment and Nutrition Diagnosis:If yes: Evidence for Assessment and Nutrition Diagnosis: 2. Is there initial documented evidence in the Assessment 2. Is there initial documented evidence in the Assessment

portion of the note to support portion of the note to support a nutrition diagnosis?a nutrition diagnosis? YesYes No No a related etiology?a related etiology? YesYes NoNo

3. Does the PES diagnostic statement show clear 3. Does the PES diagnostic statement show clear relationship among nutrition diagnosis, etiology, and relationship among nutrition diagnosis, etiology, and signs and symptoms?signs and symptoms? Yes Yes NoNo

4. Is extraneous information included in the note that is 4. Is extraneous information included in the note that is not related to the identified Diagnosis of interest?not related to the identified Diagnosis of interest?

YesYes NoNo

GoalGoal For a documented patient goal is there a related For a documented patient goal is there a related

documented nutrition diagnosis?documented nutrition diagnosis? Yes____ No____Yes____ No____ Documented nutrition etiology? Yes____ No____Documented nutrition etiology? Yes____ No____ Goal not recorded____Goal not recorded____


Evaluation, ContinuedEvaluation, ContinuedInterventionIntervention 6. For each patient goal is there a related documented 6. For each patient goal is there a related documented

plan plan for an intervention or actual intervention?for an intervention or actual intervention?

Yes____No____Intervention not recorded____Yes____No____Intervention not recorded____

7. Does Intervention section include summary of actual 7. Does Intervention section include summary of actual intervention already implemented to date? Yes____ No____intervention already implemented to date? Yes____ No____ Not applicable____(plan included but Not applicable____(plan included but not implemented)not implemented)

8. Does Intervention section include a Plan for Monitoring 8. Does Intervention section include a Plan for Monitoring and Evaluating progress toward patient goals?and Evaluating progress toward patient goals?

Yes____No____Yes____No____


Evaluation, ContinuedEvaluation, ContinuedMonitoring and EvaluatingMonitoring and Evaluating

Not a follow-up note______ orNot a follow-up note______ or

9. For follow-up notes, does the Assessment section 9. For follow-up notes, does the Assessment section include a documented patient outcome as indicated in include a documented patient outcome as indicated in previous note that is related to a documented patient goal? previous note that is related to a documented patient goal?

Yes____No____Outcome not recorded____Yes____No____Outcome not recorded____

10. Does the follow-up note in the Assessment section 10. Does the follow-up note in the Assessment section include a statement that identifies the progress toward include a statement that identifies the progress toward patient goals.patient goals.Yes____No____Progress not recorded____Yes____No____Progress not recorded____


Steps: Begin PilotSteps: Begin Pilot

Pilot begins on date selectedPilot begins on date selected

1 RD – Coverage area (for example, 1 RD – Coverage area (for example, ICU, Neurosurgery, or other specific ICU, Neurosurgery, or other specific unit)unit)

All notes to be written in ADI format All notes to be written in ADI format for initial; ME for follow-upfor initial; ME for follow-up


Findings from Chart AuditsFindings from Chart Audits

Outcomes monitoring is an issue with short Outcomes monitoring is an issue with short hospital stayshospital stays

Desire to use “Potential for” when problem does Desire to use “Potential for” when problem does not exist now– do not document that.not exist now– do not document that.

Temporary situations Temporary situations Patient with temporary inadequate energy intake RT Patient with temporary inadequate energy intake RT

holding enteral feeds AEB order to extubate patientholding enteral feeds AEB order to extubate patient


Findings from Chart Findings from Chart AuditsAudits

Ensure the staff know that opportunities for improvement are Ensure the staff know that opportunities for improvement are expected!! Some opportunities identified at other facilities expected!! Some opportunities identified at other facilities included:included: Outcomes monitoring is an issue with short hospital staysOutcomes monitoring is an issue with short hospital stays Desire to use ‘Potential for’ when problem does not exist Desire to use ‘Potential for’ when problem does not exist

now, but might in the futurenow, but might in the future Desire to modify or reword nutrition diagnostic terminologylDesire to modify or reword nutrition diagnostic terminologyl Temporary situationsTemporary situations

Patient with temporary inadequate energy intake RT Patient with temporary inadequate energy intake RT holding enteral feeds AEB order to extubate patientholding enteral feeds AEB order to extubate patient

Questions about how to capture all information provided by Questions about how to capture all information provided by patient’s family, but isn’t pertinent to current problem patient’s family, but isn’t pertinent to current problem


Finally!!Finally!!

Everyone on board – about two monthsEveryone on board – about two months Many questions remain regarding formatting Many questions remain regarding formatting

specificsspecifics When there is When there is

Not enough data or evidence for an etiologyNot enough data or evidence for an etiology No new labs, data available for outcomes No new labs, data available for outcomes

monitoringmonitoring Specifics of documenting outcome monitoring Specifics of documenting outcome monitoring

and evaluation of goalsand evaluation of goals Some MD’s expect the RD to evaluate issues Some MD’s expect the RD to evaluate issues

that are not specifically nutrition problems, i.e. that are not specifically nutrition problems, i.e. blood glucose elevated due to corticosteroid blood glucose elevated due to corticosteroid use (not a nutrition related problem.)use (not a nutrition related problem.)


Final Thoughts from Final Thoughts from Pilot TestPilot Test Use of reference book imperativeUse of reference book imperative

Start small – practice PES format Start small – practice PES format firstfirst

Individual and Group TrainingIndividual and Group Training Audit by Manager or Team – helpful!Audit by Manager or Team – helpful! Through implementation, keep in Through implementation, keep in

mind that this is a learning mind that this is a learning process…keep our minds open. process…keep our minds open. EmbraceEmbrace, do not fear, , do not fear, changechange..


Expect and Discuss Some Expect and Discuss Some Common Questions Up Common Questions Up

FrontFront A FEW initial questions and comments A FEW initial questions and comments

from other sitesfrom other sites ““Can I use 2 diagnostic terms?”Can I use 2 diagnostic terms?”

Yes if you intend to address both in the intervention, but simpler is Yes if you intend to address both in the intervention, but simpler is betterbetter

What about the “not at risk patient”?What about the “not at risk patient”? Indicate the reason for assessment and indicate that there is no Indicate the reason for assessment and indicate that there is no

problem at the current timeproblem at the current time ““This is taking much longer than I thought it would!”This is taking much longer than I thought it would!”

Acknowledge that this is true…try to accommodate it in workload Acknowledge that this is true…try to accommodate it in workload sharing if possible. Remember how long it took you to do your very sharing if possible. Remember how long it took you to do your very first assessment and progress note….this will be similar because it first assessment and progress note….this will be similar because it is new to you at this point.is new to you at this point.

““What if there is no current nutrition problem, but I have What if there is no current nutrition problem, but I have to follow due to facility protocols?”to follow due to facility protocols?”

Indicate “no nutrition diagnosis/problem at this time.” Address Indicate “no nutrition diagnosis/problem at this time.” Address interventions based on what potentially may be continued ie) diet interventions based on what potentially may be continued ie) diet order. M&E may consist of what parameters you will reassess when order. M&E may consist of what parameters you will reassess when you return for follow-up.you return for follow-up.


Anticipate Thoughts and Anticipate Thoughts and Questions after First Questions after First

ImplementationImplementation Time and Patient Load are issuesTime and Patient Load are issues Still struggling with linking appropriate ‘E’ Still struggling with linking appropriate ‘E’

and ‘S’ to ‘P’and ‘S’ to ‘P’ The urge to make blanket statements for ‘M’ The urge to make blanket statements for ‘M’

and ‘E’ still remains: i.e. monitor labs and poand ‘E’ still remains: i.e. monitor labs and po Follow-up notes remain a challengeFollow-up notes remain a challenge Overall the process is becoming more clear Overall the process is becoming more clear

and notes are more focused and concise in and notes are more focused and concise in format, but the VHC dietitians still feel there format, but the VHC dietitians still feel there are many unanswered questionsare many unanswered questions..


Many questions remain Many questions remain regarding formatting regarding formatting

specificsspecifics Not enough data or evidence for an etiologyNot enough data or evidence for an etiology No new labs, data available for outcomes No new labs, data available for outcomes

monitoringmonitoring How specific do we need to be in outcome How specific do we need to be in outcome

monitoring and evaluation of goalsmonitoring and evaluation of goals Some MD’s expect the RD to evaluate certain Some MD’s expect the RD to evaluate certain

issues that may not be specific nutrition issues that may not be specific nutrition problems, i.e. blood glucose elevated due to problems, i.e. blood glucose elevated due to steroid medication not a nutrition related steroid medication not a nutrition related problem. Results in teaching moment with problem. Results in teaching moment with MD, other cliniciansMD, other clinicians


Peer Network for Peer Network for Nutrition DiagnosisNutrition Diagnosis--

PNND PNND (Expanded (Expanded Pilot)Pilot)

17 RDs selected to represent ADA Members 17 RDs selected to represent ADA Members (2005(2005)) Geographic regionsGeographic regions SettingsSettings Areas of practiceAreas of practice

Names posted on ADA WebsiteNames posted on ADA Website Webinars held for training Webinars held for training FNCE sessions each year since 2006FNCE sessions each year since 2006 Presentations at State Dietetic Associations + Presentations at State Dietetic Associations +

DPGsDPGs Over 100 volunteeredOver 100 volunteered

Asked to participate in Nutrition Diagnosis SurveyAsked to participate in Nutrition Diagnosis Survey Survey mailed Jan 2006Survey mailed Jan 2006


Each facility is differentEach facility is different

Contractual Management versus “Self-Op”Contractual Management versus “Self-Op” Teaching Hospital versus Non-TeachingTeaching Hospital versus Non-Teaching VA, CARLE, and Virginia Hospital all VA, CARLE, and Virginia Hospital all

differeddiffered Assess your facility and its Assess your facility and its

environment/cultureenvironment/culture Assess your staff and their readiness levelAssess your staff and their readiness level

Learning LevelsLearning Levels Acceptance LevelsAcceptance Levels Compliance LevelsCompliance Levels


Select Documentation Select Documentation FormatFormat

Modified SOAP formatModified SOAP format PES statement at conclusion of A sectionPES statement at conclusion of A section

ADI format ADI format Narrative with PES statementNarrative with PES statement Discuss how to handle routine “screening” Discuss how to handle routine “screening”

assessments where there is no problem assessments where there is no problem (lower risk pts/clients)(lower risk pts/clients)

Determine your guidelines for how much is Determine your guidelines for how much is enough, too much, just rightenough, too much, just right Examples provided in handout materials as Examples provided in handout materials as

starting point for your facilitystarting point for your facility Establishing documentation guidelines are very Establishing documentation guidelines are very

helpfulhelpful


The Evolution Process The Evolution Process During ImplementationDuring Implementation

Continuing practice with other RDsContinuing practice with other RDs Consider “mentor” groups/teamsConsider “mentor” groups/teams Daily notes sent to CNM for audit Daily notes sent to CNM for audit

(10%)(10%) Reviewing errors one-on-oneReviewing errors one-on-one Holding weekly group review Holding weekly group review

sessionssessions


In The End, Performance In The End, Performance Improvement Will ShowImprovement Will Show

Overall – documentation and charting Overall – documentation and charting speed increasedspeed increased

Notes with greater consistency and Notes with greater consistency and focusedfocused

Monitoring and Evaluation techniques Monitoring and Evaluation techniques clearly statedclearly stated

Outcomes in patients with greater LOS Outcomes in patients with greater LOS easier to monitor and track due to easier to monitor and track due to specificity of chart notespecificity of chart note

Training new staff members – formalized Training new staff members – formalized Improves Quality of CareImproves Quality of Care


Nutrition Care Process Nutrition Care Process ResourcesResources

Many resources available to membersMany resources available to members ADA website materials and tutorialsADA website materials and tutorials PresentationsPresentations BooksBooks Published ArticlesPublished Articles Speakers BureauSpeakers Bureau Members of Committees and Peer Members of Committees and Peer

Network for Nutrition Diagnosis Network for Nutrition Diagnosis Evidence-Based Guides ToolkitsEvidence-Based Guides Toolkits

10.A.7


Just think…Just think…

““He who stops He who stops being better stops being better stops being good.”-- being good.”-- Oliver CromwellOliver Cromwell

The Moral: NEVER The Moral: NEVER stop being better.stop being better.


In summary…In summary…

The Nutrition Care Process The Nutrition Care Process and Standardized and Standardized Language will take us to a Language will take us to a new level of performance new level of performance and recognition.and recognition.


AcknowledgementsAcknowledgements

Kotter, J. Leading Change', Harvard School Press Kotter, J. Leading Change', Harvard School Press 19961996CARLE Research Project – Nutrition Diagnosis CARLE Research Project – Nutrition Diagnosis

in Ambulatory Medicare populationin Ambulatory Medicare populationPilot Projects – Virginia and VA in San DiegoPilot Projects – Virginia and VA in San Diego

Lacey K and Pritchett E. Nutrition Care Lacey K and Pritchett E. Nutrition Care Process and Model. Process and Model. J Am Diet Assoc. J Am Diet Assoc. 2003;103(8): 1061-1072.2003;103(8): 1061-1072.International Dietetics and Nutrition International Dietetics and Nutrition Terminology (IDNT) Reference Manual. Terminology (IDNT) Reference Manual. Chicago, IL: American Dietetic Association. Chicago, IL: American Dietetic Association. 20082008Sherri J. UPMC Presbyterian Shadyside. PNNDSherri J. UPMC Presbyterian Shadyside. PNND


Questions???Questions???

Esther MyersEsther Myers

[email protected]@eatright.org

nutrition care process and change management: making it happen in dietetics!

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